Infection control spot checks

Overview

Under the Aged Care Quality Standards (Quality Standards) in the Aged Care Act 1997, every aged care provider is responsible for ensuring that they have sufficient staff with the necessary knowledge and skills to provide safe, respectful and quality care and services. Providers are also responsible for ensuring that staff are appropriately training in important processes such as infection control and appropriate use of personal protective equipment (PPE).

The Aged Care Quality and Safety Commission (the Commission) undertakes a range of regulatory activities to monitor compliance and mitigate the risk to aged care consumers.  These activities are aimed at ensuring that providers meet their obligations with respect to the Quality Standards and implement all necessary steps to minimise the risks of transmission of the virus consistent with the advice of health authorities. 

Where there is heightened risk due to one or more positive COVID-19 cases being identified in the vicinity of an aged care home(s), the Commission will target its activities to those areas of risk. This may include issuing an alert email to providers to heighten provider awareness, increasing onsite infection control monitoring visits to services in particular locations, and/or undertaking phone-based assessments with contacts focusing on outbreak preparedness. Where risk is identified through these contacts, information is provided to the jurisdictional health department and the Department of Health. In line with agreed joint protocols, jurisdictions and the Commonwealth work together to respond to the risk of COVID-19 transmission to residential aged care facilities in a timely and coordinated manner.

From 1 March 2020 to early 2021, the Commission undertook targeted infection control monitoring visits, including spot checks, in the majority of residential aged care services across Australia. These visits involved monitoring infection and prevention control practices and service preparedness for possible COVID-19 outbreaks. The Commission has now incorporated the targeted spot check monitoring infection control practice into its usual regulatory activities. The Commission will, should it be necessary, stand up targeted spot checks or undertake other regulatory activities to respond rapidly if there is a heightened risk of community transmission that may impact aged care services. 

Officers conducting the visits use a range of tools, including reviewing the services’ outbreak management plan (OMP) against the best practice principles based on the National Guidelines for the Prevention, Control and Public Health Management of Outbreaks of Acute Respiratory Infection (including COVID-19 and Influenza) in Residential Care Facilities. In addition, an infection control monitoring checklist is used as a guide during some visits.  Providers are also asked additional questions to understand how they are applying public health directives relating to infection control which is specific to the directions in their state or territory. 

As of 1 December 2020, each aged care facility (each service location) is required to have appointed at least one designated member of the nursing staff as an Infection and Prevention Control (IPC) lead. Further information about IPC leads can be found on the Commission’s website. 

Findings from infection control monitoring visits during 2020

Overall the Commission was satisfied with what was observed at most infection control spot checks in 2020. The Commission observed some services with good infection practices, but also noted some deficiencies in practice. Where deficiencies or non-compliance was detected, the Commission took proportionate regulatory action to ensure providers addressed the issues identified.  

The response of services to the Commission conducting infection control monitoring visits varied. Generally, services were positive and open to visits. They advised they were aware of the Commission’s unannounced infection control management plan visits and were looking forward to the Commission visiting to clarify whether they were doing the right thing. However, managers also reported feeling overwhelmed by the frequent contact from the Commission, state/territory health departments, and local public health units.

What providers are doing well

• Most services have OMPs which are reviewed regularly and importantly, contain all relevant information in an easy-to-read format. 
• A large proportion of providers have floor plans showing room configurations, donning and doffing stations, and clearly marked command centres, staff break rooms, and alternative access points.
• Some providers have laminated floor plans to use as a living document that can be updated as required. One service has printed a table-sized floorplan with photographs of consumers that can be attached to the floorplan by Velcro for easy identification and placement within the service. 
• Some providers have demonstrated a high level of preparedness by undertaking drills using their OMP, including the allocation of staff to various leadership roles and testing staff in their roles and responsibilities. 
• Most providers are screening staff and visitors on entry.
• Large amounts of staff have completed infection control competencies.
• Some services have comprehensive surge workforce planning

What could be improved

Our observations from the infection control spot checks highlighted some common areas where providers could improve or revisit their processes. 

In locations where PPE is a requirement (in accordance with state/territory directions), our officials observed some occasions where aged care staff were:

• wearing masks incorrectly
• frequently touching their face and/or mask
• not routinely cleaning shared resident equipment such as patient lifters.  

In some services, there were also issues of:

• donning and doffing stations not being clearly identified
• failing to have PPE (such as gloves, masks, hand washing/alcohol-based hand sanitiser, and disinfectant wipes) readily available.

In some instances, aged care staff were wearing PPE when it was not required under state/territory directions.

While services may have been vigilant in their infection control practices for residents, the Commission staff were surprised at how often they observed staff not using proper infection control around each other. Examples of this were:

• shared equipment, such as phones or computers not routinely being wiped down between users 
• lack of physical distancing between staff
• no clear signage to identify the permissible number of staff in common areas such as offices, break, and changing rooms.

OMPs and governance

While many providers had OMPs in place, there were some common issues identified such as:

• OMPs being developed at the corporate level and not being service-specific to address the differences in layout and individual needs of residents at each service
• not all plans had clearly identifying cohorting zones and/or rooms where PPE donning and doffing stations are or would be, located
• OMPs being incomplete
• service personnel being unaware of where OMPs were stored and/or being unable to access them when senior management were not onsite.
   

New ideas and innovations noted during the visits

Innovative methods to support staff 

• Services that organised laundering of staff uniforms or providing ‘scrubs’ to ensure that each staff member had a clean uniform every day.
• Transporting staff to and from work in a bus provided by the service to prevent staff needing to take public transport.
• Creating a song about the donning and doffing process to support staff to learn and remember the correct procedure in an effective and fun way.
• Relocating upper and middle managers out of the main aged care service into different buildings to have senior staff available who can replace onsite staff who must isolate in the event of an outbreak.

Maintaining continuity of care for residents

• Preparing ID wristbands in advance for each resident to help agency and surge workforce identify residents. This is particularly useful if a large number of the usual workforce becomes furloughed.
• Having a ‘COVID-19 outbreak – How to look after me’ box which contains care plans and other supporting documentation for each resident to assist any surge or agency workforce with handover arrangements. Although this is outlined in the infection control management plan checklist, having the information organised and available in an easily accessible and user-friendly manner was unique and effective.
• Services continuing their partnership in care programs to support consumers maintaining well-established connections with a nominated or substitute representative during lockdown.
• Keeping up communication between residents and families during lockdown, through phone calls, WhatsApp conversations, window visits and balcony visits.

Creative management and prevention of COVID-19 

• Sophisticated staff tracking devices that tracked and registered on a database when staff had been in a room for more than 10 minutes. In the event of an outbreak, this allowed the service to run a report about which staff members and residents may be at risk.
• Face-scanner technology that was able to do a complete face scan (as opposed to forehead only) for temperatures.
• Independent services who attended local network meetings to discuss plans for surge workforce and hospital transfers in their area, demonstrating their efforts to work closely with emergency services in a small community.

About infection control monitoring visits

The targeted infection control spot checks were monitoring visits, not performance assessments. Where issues or concerns were identified during spot checks, the Commission considered further regulatory action to ensure the provider is meeting their quality and safety obligations. This may include a performance assessment against the Quality Standards or imposing sanctions. The infection control checklist is now also used as part of each service visit, including site audits.

The targeted infection control site visits are made by officers authorised by the Commissioner. The officers: 

• have authority to enter services, with consent, under Part 8 of the Aged Care Quality and Safety Commission Act 2018, with officers showing relevant identification when seeking consent
• in visiting residential aged care facilities, are exercising functions and powers of the Commission under Commonwealth legislation that is recognised by state and territory health authorities
• have undertaken PPE training to meet best practice and state-based requirements
• have completed a declaration to confirm: their participation and understanding of the PPE training; agreement to use PPE as instructed; that they have had their influenza vaccination 
• undergo daily screening regarding any fever or symptoms of acute respiratory infection; contact with a confirmed case of COVID-19 or persons awaiting test results; and a temperature check based on expert medical advice
• comply with the infection control processes and screening requirements of workers of the service on entry, such as complying with any entry requirements consistent with public health directions and/or infection control requirements 
• confirm that they have not been to sites with confirmed cases of COVID-19 or had any known contact with COVID-19. (Please note: in doing so, the officers are not able to disclose the names of any services visited as this is protected information under the Aged Care Quality and Safety Commission Act)
• comply with current interstate travel restrictions and quarantine requirements and with the current restriction levels in place in any restricted areas
• follow Commission notification and response protocols if services have any COVID-19 positive cases after the officers have left the service. 

A record of the regulatory official’s observations of the service environment, consumers, and staff practices are emailed to the provider of the service following the site visit. 

Queries in relation to these site visits can be made to the relevant state/territory office of the Commission or by phoning 1800 951 822 (free call). 

Resources 

Infection control monitoring checklist